Selim G Gebran1, Brooks Knighton2, Ledibabari M Ngaage1, John A Rose3, Michael P Grant1, Fan Liang1, Arthur J Nam1, Stephen M Kavic1, Mark D Kligman1, Yvonne M Rasko4,5. 1. Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA. 2. University of Maryland School of Medicine, Baltimore, MD, USA. 3. Department of Plastic & Reconstructive Surgery, The Johns Hopkins University, Baltimore, MD, USA. 4. Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA. yrasko@som.umaryland.edu. 5. Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD, 21230, USA. yrasko@som.umaryland.edu.
Abstract
BACKGROUND: Bariatric surgery remains underutilized at a national scale, and insurance company reimbursement is an important determinant of access to these procedures. We examined the current state of coverage criteria for bariatric surgery set by private insurance companies. METHODS: We surveyed medical policies of the 64 highest market share health insurance providers in the USA. ASMBS guidelines and the CMS criteria for pre-bariatric evaluation were used to collect private insurer coverage criteria, which included procedures covered, age, BMI, co-morbidities, medical weight management program (MWM), psychosocial evaluation, and a center of excellence designation. We derive a comprehensive checklist for pre-bariatric patient evaluation. RESULTS: Sixty-one companies (95%) had defined pre-authorization policies. All policies covered the RYGB, and 57 (93%) covered the LAGB or the SG. Procedures had coverage limited to center of excellence in 43% of policies (n = 26). A total of 92% required a BMI of 40 or above or of 35 or above with a co-morbidity; however, 43% (n = 23) of policies covering adolescents (n = 36) had a higher BMI requirement of 40 or above with a co-morbidity. Additional evaluation was required in the majority of policies (MWM 87%, psychosocial evaluation 75%). Revision procedures were covered in 79% (n = 48) of policies. Reimbursement of a second bariatric procedure for failure of weight loss was less frequently found (n = 41, 67%). CONCLUSIONS: A majority of private insurers still require a supervised medical weight management program prior to approval, and most will not cover adolescent bariatric surgery unless certain criteria, which are not supported by current evidence, are met.
BACKGROUND: Bariatric surgery remains underutilized at a national scale, and insurance company reimbursement is an important determinant of access to these procedures. We examined the current state of coverage criteria for bariatric surgery set by private insurance companies. METHODS: We surveyed medical policies of the 64 highest market share health insurance providers in the USA. ASMBS guidelines and the CMS criteria for pre-bariatric evaluation were used to collect private insurer coverage criteria, which included procedures covered, age, BMI, co-morbidities, medical weight management program (MWM), psychosocial evaluation, and a center of excellence designation. We derive a comprehensive checklist for pre-bariatric patient evaluation. RESULTS: Sixty-one companies (95%) had defined pre-authorization policies. All policies covered the RYGB, and 57 (93%) covered the LAGB or the SG. Procedures had coverage limited to center of excellence in 43% of policies (n = 26). A total of 92% required a BMI of 40 or above or of 35 or above with a co-morbidity; however, 43% (n = 23) of policies covering adolescents (n = 36) had a higher BMI requirement of 40 or above with a co-morbidity. Additional evaluation was required in the majority of policies (MWM 87%, psychosocial evaluation 75%). Revision procedures were covered in 79% (n = 48) of policies. Reimbursement of a second bariatric procedure for failure of weight loss was less frequently found (n = 41, 67%). CONCLUSIONS: A majority of private insurers still require a supervised medical weight management program prior to approval, and most will not cover adolescent bariatric surgery unless certain criteria, which are not supported by current evidence, are met.
Entities:
Keywords:
Bariatric; Insurance; Reimbursement; Weight loss surgery
Authors: Lauren M Gibbons; David B Sarwer; Canice E Crerand; Anthony N Fabricatore; Robert H Kuehnel; Patti E Lipschutz; Steven E Raper; Noel N Williams; Thomas A Wadden Journal: Obesity (Silver Spring) Date: 2006-03 Impact factor: 5.002
Authors: Kaitlin M Love; J Hunter Mehaffey; Dana Safavian; Bruce Schirmer; Steven K Malin; Peter T Hallowell; Jennifer L Kirby Journal: Surg Obes Relat Dis Date: 2017-01-13 Impact factor: 4.734
Authors: Fatima Cody Stanford; Daniel B Jones; Benjamin E Schneider; George L Blackburn; Caroline M Apovian; Donald T Hess; Sarah Chiodi; Shirley Robert; Ashley C Bourland; Christina C Wee Journal: Surg Endosc Date: 2014-12-10 Impact factor: 4.584
Authors: Jeffrey I Mechanick; Adrienne Youdim; Daniel B Jones; W Timothy Garvey; Daniel L Hurley; M Molly McMahon; Leslie J Heinberg; Robert Kushner; Ted D Adams; Scott Shikora; John B Dixon; Stacy Brethauer Journal: Obesity (Silver Spring) Date: 2013-03 Impact factor: 5.002
Authors: Amresh D Hanchate; Danyang Qi; Michael K Paasche-Orlow; Karen E Lasser; Zhixiu Liu; Mengyun Lin; Kristina Henderson Lewis Journal: JAMA Health Forum Date: 2021-10-08